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  • POSTGRAD. MED. J. (I964), 40, 36

    ACUTE SUPPURATIVE PERICARDITIS With Death from Ruptured Mycotic Aneurysm of the Aorta

    J. D. FITZGERALD, M.B.,(N.U.I.), B.Sc., M.R.C.P.(Ed.)* MARTIN W. McNICOL, M.B.(Glasg.), M.R.C.P.t

    From the Sully Hospital, Penarth, Glam.

    ACUTE suppurative pericarditis is a rare disease, usually resulting from a local cause, or associated with a debilitating illness. The prognosis has been much improved by antibiotics, but treatrnent is still difficult. The case reported here is one in which suppurative pericarditis was apparently a primary condition; after a protracted illness, the patient died as a result of a complication that has not been previously recorded.

    Case Report The patient, a 52-year-old male pharmacist, was

    admitted to Sully Hospital on 20.5.6i. Six weeks earlier he had noted lassitude and a feeling of vague ill health. Ten days later he developed slight itching in both ears and a dry throat. He was put to bed and was given oxytetracycline ig./day for five days with some improve- ment. Eight days later the dry throat and itching in the ears recurred, and were now accompanied by fever and low backache. He was again put to bed and was given benzyl penicillin I megaunit/day for seven days, followed by phenethicillin ig./day and 'virugon'. There was a slight improvement and he was then sent for a chest X-ray which showed a small right pleural effusion. He was therefore admitted to Cardiff Royal Infirmary. Examination there showed the signs of a right pleural effusion, and an enlarged but not tender liver. 200 ml. of blood-stained fluid were removed by pleural aspira- tion; the fluid contained 99% red cells with I% neutro- phils, and was sterile on culture. The patient was trans- ferred to Sully Hospital for further investigation. He was a moderately obese man. Though afebrile

    (T.98°F.), he looked ill and was very distressed and restless. The jugular venous pressure was elevated and showed no pulsation. There was no peripheral cedema. Pulse regular, rate ioo/min.; blood pressure 130/90 mm. Hg. A protodiastolic triple rhythm was present; there were no cardiac murmurs and no pericardial friction rub was heard. Examination of the chest showed the signs of a right pleural effusion. The abdomen was very distended and tympanitic; the liver and spleen were not enlarged and bowels sounds were present. The other systems showed no abnormality.

    Investigations. Chest X-ray (Fig. I) showed cardiac enlargement, slight broadening of the mediastinum and a small right pleural effusion. The ECG showed ST- segment changes consistent with pericarditis. Sputum culture gave a profuse growth of Monilia albicans together with a coagulase-positive Staphylococcsts aureus which was sensitive to streptomycin, chloram- phenicol and erythromycin. A coagulase negative staphylococcus, almost certainly a contaminant, was

    Present address: United Research Laboratories, Ciba, Basle.

    t Present address: Central Middlesex Hospital, Park Royal, London, N.W.IO.

    FIG. I.-Postero-anterior chest X-ray on admission to hospital showing cardiac enlargement, mediastinal broadening, and right pleural effusion.

    grown on blood culture. Hb. 9.5 g./xoo ml., w.b.c. 24,000/cu. mm. (87% neutrophils). ESR (Westergren) 6i mm./hour. Urine-no glucosuria, but moderate albuminuria with a few hyaline casts but no cells. Blood urea go mg./0oo ml. Serum electrolytes normal. Serum proteins and electrophoresis-increased gamma-globu- lin, but otherwise normal. Serum bilirubin 0.5 mg./ 0OO ml. SGOT 75 units. SGPT ioo units. Mantoux reaction-12 mm. induration to Ioo T.U. Anti- streptolysin 'o' titre 50 units. The following were negative: Coomb's test, L.E.

    cells (x6), virus agglutinations (for influenza, A.P.C., Q. fever, psittacosis, L.G.V., lymphocytic choriomenin- gitis, and mumps), cold agglutinins, Paul-Bunnell, agglutination reactions for Brucella, and Wasserman and Kahn reactions.

    Progress. The patient's distress, the elevated non- pulsating jugular venous pressure, the chest X-ray, and the cardiographic changes all suggested pericardial effusion with tamponade. Aspiration was performed by the subcostal route and 270 ml. of cloudy yellow fluid was withdrawn to the great relief of the patient. Exam- ination of the fluid showed many neutrophils, and on culture there was a pure growth of coagulase positive Staphylococcus aureus (phage type 29/52/52A/8i), fully sensitive to penicillin, tetracyclines, erythromycin, streptomycin, and chloramphenicol. Treatment had been started with a low salt diet, digoxin and chloro- thiazide; in view of the findings in the pericardial fluid, benzlypenicillin io megaunits/day and oxytetracycline 2 g./day were also given. The penicillin was continued for io days and the oxytetracycline for 2I days.

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  • January I964 FITZGERALD and McNICOL: Acute Suppurative Pericarditis 37

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    FIG. 2.-Postero-anterior chest X-ray after inj'ection of 'Hypaque' showing an intact pericardium with no leakage of the contrast medium.

    There was a slow improvement with diuresis and loss of weight, but the venous pressure remained elevated. Distress and restlessness recurred quickly and during the next 20 days seven pericardial aspirations were required, and a total of three litres of purulent fluid was removed. The staphylococcus persisted throughout, and by the tenth day of treatment, sensitivity to penicil- lin had been lost. Methicillin 6 g/day was then substi- tuted, and streptomycin i g./day with I.N.A.H. 300 mg./ day were also given lest the condition be primarily tuberculous. By 22nd June, despite apparently adequate chemotherapy, the staphylococcus was sensitive only to methicillin. At this stage, in an attempt to exclude tracking of infection from an extrapericardial source, 35 ml. of 'Hypaque 70' at 370 C. were injected into the pericardium; subsequent X-rays (Fig. 2) showed an intact pericardium. As anxiety was still felt about the diagnosis and the course of the illness which did not seem to be like that of a pyogenic pericarditis, bron- choscopy was carried out on 22.6.6I. The right lower lobe bronchus was seen to be compressed, but no other abnormality was observed.

    Right thoracotomy (Mr. H. R. S. Harley) was performed immediately after bronchoscopy. The whole mediastinum from the apex of the heart to the azygos vein was densely hard and infiltrated with fibrous tissue. The superior vena cava was dilated and tense and did not deflate when the pericardium was opened. The pericardial sac contained two litres of yellow fluid. The heart was normal in size. The appearances were thought to be suggestive of malignant disease. In view of the necessity for repeated pericardial aspirations, a window was made from the pericardium into the right pleural sac. A biopsy taken from the mediastinum showed organising pericarditis and mediastinitis only.

    Post-operative course was uneventful, and no further paracentesis was necessary. On the eighth post-

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    FIG. 3.-The heart and great vessels. The very severe fibrinous pericarditis is clearly seen. The ruptured false aneurysm is shown by the arrow.

    FIG 4 Superficial myocardium, epicardium and pericardium (low power, H. and E.). Inflammatory changes involving the superficial parts of the myocardium, thickening of the epicardium, and fibrosis thickening and chronic inflammation of the pericardium.

    operative day, the patient suddenly collapsed and died within thirty minutes. There was marked pallor suggest- ing blood loss. Vigorous attempts at resuscitation were unsuccessful.

    Autopsy (Dr. R. M. E. Seal). The pericardium was greatly thickened and showed signs of inflammation; the mediastinum was much indurated. In the right side of the superior mediastinum, there was a fluctuant hemorrhagic mass, which had ruptured into the pleural cavity above the azygos vein, filling the right pleural

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  • POSTGRADUATE MEDICAL JOURNAL

    sac with blood. Dissection showed a mycotic aneurysm of the aorta at the junction of the ascending part and the arch. A defect in the aortic wall led to a false aneurysmal sac 3 cm. in diameter, and it was this false aneurysm which had ruptured into the pleura (Fig. 3). The heart was normal apart from the pericarditis. Apart from congestion of the liver, there was no other abnormality; in particular there was no primary source of infection, and there were no metastatic abscesses. Histological examination (Fig. 4) confirmed the presence of an organising mediastino-pericarditis. Numerous Gram positive cocci were present in the sections. There was no evidence of any other disease.

    Discussion The striking signs in this patient were those of

    cardiac tamponade and not those of an acute pyogenic infection. In the 425 cases of suppurative pericarditis reviewed by Boyle (I96I) local or general predisposing factors were present in all, and signs of acute infection were common, though the presence of pericarditis was sometimes un- suspected. In the present case, no source of infec- tion could be identified and there was no local or general predisposing factor. The exact nature of the prodromal illness